Skywork D328 at Bern on Dec 7th 2015, went off runway while backtracking for departure
Last Update: October 3, 2018 / 16:19:29 GMT/Zulu time
Switzerland's SUST released their final report in German only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a German only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe) concluding the probable causes of the serious incident were:
The serious incident consisted of a barely avoided collision with obstacles because the aircraft was taxiing to the takeoff position at a speed that was not adjusted to the marginal visibility, the loss of situation awareness by the crew so that the aircraft could not be stopped in time. As result the aircraft came to a stop just past the runway turn pad in grass and just before the approach lighting.
The following factors contributed to the serious incident:
- the priorities were not set in accordance with the situational needs
- runway turn pad edge lightning hard to detect
The SUST reported that the recovery of the aircraft was performed not according to the aircraft recovery manual. As result there were concerns the main gear could have been overstressed during recovery. The operator replaced the main gear following a computation of stresses encountered during recovery. The removed gear was examined by the manufacturer and found serviceable finding that the landing gear had not been stressed beyond limits during the recovery.
The SUST analysed that the turn pads and lightings are in accordance with the ICAO/EASA requirements. However, the situation is not satisfactory nonetheless as the turn pad is no longer part of the runway although providing the same specifications with respect to surface properties, load capacity and dimensions. Because of this aircraft are forced to taxi beyond the red runway end lights each time the turn pad is to be used. This contradicts the principle that red lines must not be passed, a clearance to pass the red runway end lights would not be issued by air traffic control.
In addition the edge lights of the turn pad were hard to detect, the approach lights runway 14 were dominant and was more of an eyecatcher in addition to the poor visibility.
The SUST analysed that the icings speeds were brought up by the first officer only after the captain had already steered the aircraft onto the runway center line backtracking runway 14 and tower had reported 600 meters RVR. Instead of simply turning the pages of the speed booklet (according to instruction on the active reference speed page to immediately have the relevant icing speed available) the first officer engaged into computing the speeds via his electronic flight bag, while the low visibility required the attention of both pilots for taxiing.
In the meantime the captain accelerated the aircraft up to 30 knots over ground. The first officer did not monitor the progress of the taxi while being busy to compute the icing speeds and subsequently put them into the flight management system. This lack of mutual supervision violated the closed loop principle and was not safety minded as the priority was not directed at safe taxiing. This further led that the exact position of the aircraft was no longer known and the loss of situational awareness. When the captain noticed he had lost situational awareness, he applied brakes - this decision was correct - however due to the high speed over ground it was no longer possible to stop the aircraft within the paved surface of runway/turn pad.
Aircraft Registration Data
This article is published under license from Avherald.com. © of text by Avherald.com.
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